Meta-analysis on surgical management of colonic injuries in trauma: to divert or to anastomose?

Colon injuries in the presence of complete spinal cord injury: Primary repair or colostomy?

BACKGROUND

Complete spinal cord injury (SCI) is associated with severe colon dysmotility and therefore may be associated with higher risk of leak following primary repair or anastomosis for concomitant colon injury.

METHODS

TQIP database study, patients with complete SCI and associated colon injuries who underwent primary repair (PR) or resection with primary anastomosis (RPA) were compared to those who underwent ostomy alone using propensity score matching.

RESULTS

Ninety-nine patients treated with a colostomy were matched with 215 treated with PR or RPA. Patients treated with colostomy were more likely to develop severe sepsis post-operatively (13.1 ​% vs 4.2 ​%, p ​= ​0.004). Subgroup analysis, comparing colostomy versus PR or colostomy versus RPA, showed again a higher incidence of postoperative severe sepsis in the colostomy group.

CONCLUSIONS

Primary repair and/or RPA are associated with a lower incidence of postoperative severe sepsis than colostomy and should be considered in patients with combined SCI and colon injury.

Analysis of outcomes of penetrating colonic injuries managed with or without fecal diversion

Traumatic colorectal injuries can be managed by either fecal diversion or primary repair / resection and anastomosis. We aimed to study differences in outcomes in adult patients managed with or without fecal diversion at time of initial operation. The National Trauma Databank (NTDB) was used to identify adult patients (ages 18-64 years) with penetrating colonic injuries for the years 2013-2015. We included patients with Injury Severity Score (ISS) of 9-24 excluding patients with concomitant extra-abdominal Abbreviated Injury Scale (AIS) score of 3 or more. Subjects arriving without signs of life, expiring in ER or with missing data were excluded. Data was collected for age, gender, vital signs on presentation, discharge disposition and length of stay (LOS). Patients were divided into two groups based on whether or not fecal diversion was performed within 1 day of presentation. Primary outcome assessed was in-hospital mortality and unplanned return to OR. Secondary outcomes were acute kidney injury (AKI), acute respiratory distress syndrome (ARDS), deep vein thrombosis (DVT), pulmonary embolism (PE), pneumonia, organ surgical site infection (SSI), deep SSI, severe sepsis and unplanned intubation. Statistical analysis was conducted using SPSS for windows. P-value < 0.05 was considered statistically significant. Of 2,598,467 patients, 5344 (0.21%) sustained a penetrating colonic injury. 2339 (43.8%) patients met criteria for age, ISS, AIS, signs of life and ED outcome. 173 patients underwent fecal diversion within 24 h of presentation (Group 1) while 708 did not (Group 2). Patients with missing data were excluded leaving 162 patients in Group 1 and 657 patients in Group 2. Groups 1 and 2 were noted to be similar in terms of ISS (median of 10 in both), age (median of 31 vs 29 years), percentage of male patients (85.2% vs 87.8%; p = 0.44), mean systolic blood pressure (127 mmHg vs 126 mmHg; p = 0.54), mean pulse rate (95.4 vs 94.5; p = 0.60) and mean respiratory rate (20.4 vs 20.1; p = 0.56) respectively. Median LOS was 10 days in both groups. No statistically significant differences were found between groups 1 and 2 in the primary outcomes of in-hospital mortality (2.4% vs 3.5%; OR: 1.43; 95% confidence interval (CI): 0.49-4.20) or unplanned return to OR (4.3% vs 7.8%; OR: 1.86; 95% CI: 0.83-4.19). No statistically significant differences were noted between groups 1 and 2 in the secondary outcomes of AKI (3.7% vs 3.8%; OR: 1.03; 95% CI 0.41-2.55), ARDS (1.2% VS 1.7%; OR: 1.36; 95% CI 0.30-6.21), DVT (1.9% vs 4.0%; OR: 2.18; 95% CI 0.65-7.31), PE (1.9% vs 2.0%; OR: 1.07; 95% CI 0.30-3.80), pneumonia (4.9% vs 5.3%; OR: 1.08; 95% CI 0.49-2.38), organ SSI (3.7% vs 7.0%; OR: 1.96; 95% CI: 0.82-4.67), deep SSI (3.7% vs 4.4%; OR: 1.20, 95% CI 0.49-2.94), severe sepsis (3.7% vs 3.3%; OR: 0.90; 95% CI: 0.36-2.26) or unplanned intubation (1.9% vs 1.7%; OR: 0.90; 95% CI 0.25-3.27). Adult patients with penetrating colonic injuries with ISS 9-24 in the absence of serious extra-abdominal injury who undergo surgery within 24 h of presentation do not seem to derive a statistically significant benefit from fecal diversion in terms of post-operative complications and mortality. In more severely injured patients fecal diversion may continue to provide a benefit.

Proximal protective diverting ostomy following colon anastomosis for penetrating trauma may not be protective: A matched cohort study

INTRODUCTION

Despite the shift toward liberal primary anastomosis in penetrating colon injuries, some surgeons recommend a protective diverting ostomy (DO) proximal to the anastomosis. This study evaluates the effect of DO on outcomes in patients undergoing colon resection and anastomosis following penetrating trauma.

METHODS

The TQIP database (2013-2018) was queried for penetrating colon injuries undergoing colectomy and anastomosis. Patients receiving DO were propensity matched to patients without diverting ostomy (woDO) (1:3). Outcomes were compared between groups.

RESULTS

After matching, 89 DO patients were analyzed. The DO group had more surgical site infections (32 ​% vs. 21 ​%; p ​< ​0.05) and longer hospital stay (20 [13-27] vs. 15 [9-25]; p ​< ​0.05) compared to the woDO group. Mortality and unplanned operations were similar between groups.

CONCLUSIONS

Diverting ostomy after colon resection and anastomosis is associated with increased infectious complications without decreasing unplanned operations or mortality. Its routine role in penetrating colon trauma needs reassessment.

Rates and risk factors for anastomotic leak following blunt trauma-associated bucket handle intestinal injuries: a multicenter study

Objectives

The risk factors for anastomotic leak (AL) after resection and primary anastomosis for traumatic bucket handle injury (BHI) have not been previously defined. This multicenter study was conducted to address this knowledge gap.

Methods

This is a multicenter retrospective study on small intestine and colonic BHIs from blunt trauma between 2010 and 2021. Baseline patient characteristics, risk factors, presence of shock and transfusion, operative details, and clinical outcomes were compared using R.

Results

Data on 395 subjects were submitted by 12 trauma centers, of whom 33 (8.1%) patients developed AL. Baseline details were similar, except for a higher proportion of patients in the AL group who had medical comorbidities such as diabetes, hypertension, and obesity (60.6% vs. 37.3%, p=0.015). AL had higher rates of surgical site infections (13.4% vs. 5.3%, p=0.004) and organ space infections (65.2% vs. 11.7%, p<0.001), along with higher readmission and reoperation rates (48.4% vs. 9.1%, p<0.001, and 39.4% vs. 11.6%, p<0.001, respectively). There was no difference in intensive care unit length of stay or mortality (p>0.05). More patients with AL were discharged with an ostomy (69.7% vs. 7.3%, p<0.001), and the mean duration until ostomy reversal was 5.85±3 months (range 2-12.4 months). The risk of AL significantly increased when the initial operation was a damage control procedure, after adjusting for age, sex, injury severity, presence of one or more comorbidities, shock, transfusion of >6 units of packed red blood cells, and site of injury (adjusted RR=2.32 (1.13, 5.17)), none of which were independent risk factors in themselves.

Conclusion

Damage control surgery performed as the initial operation appears to double the risk of AL after intestinal BHI, even after controlling for other markers of injury severity.

Level of evidence

III.

Penetrating colon trauma-the effect of concomitant small bowel injury on outcome

INTRODUCTION

There is limited evidence to suggest that patients with penetrating colon injury have higher complication rates when there is concomitant small bowel (SB) injury.

AIM

We performed a retrospective study looking at outcomes of penetrating colonic trauma in patients with- and without concomitant SB injury.

METHODS

We interrogated our electronic registry over an eight-year period (2012-2020) for all patients over 18 years who had sustained penetrating colon injury and who had survived beyond 72 h. Demographic data, admission physiology, and Injury Severity Score (ISS) were recorded. Two groups of patients were observed: those with colonic injury (no SB injury) and those with combined colon and SB injury. Outcomes observed included leak rates, length of Intensive Care Unit (ICU) stay, length of hospital stay (LOS), morbidity and mortality.

RESULTS

A total of 450 patients were eligible for analysis, of which 257 had colon injury without SB injury and 193 had a combination of colon and SB injury. There was no difference in mechanism of injury between groups. Admission physiology was similar between groups but arterial blood gas values were worse in the combined group. Rates of damage control surgery and ICU admission were higher in the combined group. Primary repair was done in equal proportions between groups but anastomosis was more frequently performed in the combined group. There was no difference in complication rates, including gastro-intestinal complications and suture line leaks. Length of ICU stay, LOS, and mortality were similar between groups. Univariable analysis demonstrated that the presence of concomitant small bowel injury was not an independent risk factor for colonic suture line failure or death.

CONCLUSION

There is no evidence from this data that the presence of a combined penetrating colon and SB injury should change management priorities. Each injury should be treated on its own merit, in the context of the patient's physiology.

Penetrating gluteal injuries in North West London: a retrospective cohort study and initial management guideline

Background

Penetrating gluteal injuries (PGIs) are an increasingly common presentation to major trauma centers (MTCs) in the UK and especially in London. PGIs can be associated with mortality and significant morbidity. There is a paucity of consistent guidance on how best to investigate and manage these patients.

Methods

A retrospective cohort study was performed by interrogating prospectively collected patient records for PGI presenting to a level 1 MTC in London between 2017 and 2019.

Results

There were 125 presentations with PGI, accounting for 6.86% of all penetrating injuries. Of these, 95.2% (119) were male, with a median age of 21 (IQR 18–29), and 20.80% (26) were under 18. Compared with the 3 years prior to this study, the number of PGI increased by 87%. The absolute risk (AR) of injury to a significant structure was 27.20%; the most frequently injured structure was a blood vessel (17.60%), followed by the rectum (4.80%) and the urethra (1.60%). The AR by anatomic quadrant of injury was highest in the lower inner quadrant (56%) and lowest in the upper outer quadrant (14%). CT scanning had an overall sensitivity of 50% and specificity of 92.38% in identifying rectal injury.

Discussion

The anatomic quadrant of injury can be helpful in stratifying risk of rectal and urethral injuries when assessing a patient in the emergency department. Given the low sensitivity in identifying rectal injury on initial CT, this data supports assesing any patients considered at high risk of rectal injury with an examination under general anesthetic with or without rigid sigmoidoscopy. The pathway has created a clear tool that optimizes investigation and treatment, minimizing the likelihood of missed injury or unnecessary use of resources. It therefore represents a potential pathway other centers receiving a similar trauma burden could consider adopting.

Level of evidence

2b.